The VA's Transformation of Nursing Home Care: From Nursing Homes to Community Living Centers

Hojlo, Christa, Generations

The business of providing nursing home care in the familiar medical model was being moved aside.

In April 2005, 250 Veteran's Administration (VA) employees gathered together at the first national VA Culture Transformation Summit in San Antonio, Texas. The attendees included physicians, leaders, nurses, recreation therapists, dieticians, psychologists, nursing assistants, and others who represented all members of the interdisciplinary teams. The goal was to create an urgency for change, to provide experiences that would free attendees to think beyond the current norm, and to eventually move ownership of the initiative from the national office and the steering committee to the individual VA nursing homes. This is known as building in sustainability by fostering ownership at the field or delivery level. Sustainability is necessary to build in early on so that initiatives can grow.

The business of providing nursing home care in the familiar medical model now was being moved aside to birth new life into caring for the most vulnerable patients who rely on institutional care for the most intimate and personal functions.

What precipitated this change in models? It is important to recall that into the early 1990s, nursing homes cared primarily for an elder population, some of whom were simply frail, alone, and had no other options for care or supervision. Some had dementia, which was not yet well understood. Restraints were commonly applied to "keep residents safe." There was limited knowledge about the aging process, and institutional nursing home care had no consistent standards of care for this population. Furthermore, hospital lengths-ofstay were long, often keeping those who were functionally compromised with no viable options for discharge or who were at end-of-life in the hospital until they expired.

In order to contextualize the current state of the art in nursing home care, it is necessary to reflect upon the first revolutionary changes in nursing home care mandated by the federal government through the Nursing Home Reform Act as part of the Omnibus Reconciliation Act of 1987 (commonly known as OBRA). This federal legislation created mandates to humanize nursing home environments. The OBRA recognized the individual rights of residents, releasing them from chemical and physical restraints. It also created a requirement to assess and plan care for nursing home residents using a standardized approach, and recognized that there was a need for careful oversight to ensure that United States residents were protected from harm.

During this time, the VA, along with other research colleagues, was leading efforts in the development of innovative approaches to caring for the most frail and vulnerable older adults through the establishment of geriatric research education, and clinical centers (GRECC). The VA nursing homes welcomed the findings of researchers such as Tinetti and colleagues (1988), on balance and fall prevention and Inouay and colleagues (1990), on assessing delirium. The VA took the unique opportunity to incorporate these findings into the care of veterans in VA-owned-and-operated nursing homes. At the same time, the VA also embraced the importance of interdisciplinary teams as an effective means of facilitating the achievement of resident goals and improvement in functional status.

However, the standard approach to nursing home care was based on a hospital and medical model of care delivery. Nursing home construction, both in the VA and in the private sector, mimicked the long and sterile hospital corridors, and nursing home care delivery mirrored the hospital nursing structure and management models, and resident care was diagnosis-based.

There was essentially no differentiation of reasons for nursing home admission until the Resident Instrument Minimum Data Set, implemented in United States nursing homes certified under Medicare and Medicaid in 1990, generated Resource Utilization Groups (RUG). …

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